CB20: A day in the life

This is not a scene from ER. 

Devi Sankaree Govender (Carte Blanche presenter): 'It's a tough call every day - I can see it every minute.'

Professor Graeme Pitcher (Department Head - Paediatric Surgery): 'It's a minute-by-minute call.'

These are real doctors, with real patients.

Dr Joao da Fonseca (Paediatric surgeon): 'This hospital is not really [bothered] for the feint-hearted.' 

Theirs is the story of the fight to save lives against all odds.

Professor Peter Beale (Chief Paediatric Surgeon): 'There is not always a neo-natal ventilator bed available.'

And this story is part of the Carte Blanche drive to make a difference.

Dr Da Fonseca: 'For thirty years that I've been in this hospital, this ICU is still the same.'

This is a day in the life of two of the busiest paediatric surgical units in the world.

Devi: 'Do you sometimes just want to leave it all and run away?'

Dr Barboro Monzon (Registrar): 'No, we can't. Who is going to do it?'

[07h30] It's seven-thirty at Chris Hani Baragwanath in Soweto. Dr Barbaro Monzon is doing the rounds in this makeshift paediatric surgical unit.

Dr Monzon: [examining baby's chest] 'Hey relax, relax!'

Dr Monzon: 'As you can see we have very little space for our kids at the moment. We are borrowing this veranda from the ENT ward.'

Devi: 'This is a veranda?'

Dr Monzon: 'Yes, this is a veranda for the ENT ward.'

It's a temporary plan while corporate money pays to upgrade their old ward.

Devi: 'So you have got - how many - two, four, six...?'

Dr Monzon: 'Eighteen on this side and another ten on the other side.'

Devi: 'That is it?'

Dr Monzon: 'That is it.'

[Dr Monzon gives high five to child in cot.]

Eighteen beds in a hospital that services a community of around four million.
Across the hospital, the neo-natal ward is also jam-packed.

Devi: 'How many babies do you have here?'

Dr Da Fonseca: 'Look, this is my ward. We have ten babies per cubicle, which is over-crowding and we have eight or ten cubicles... so, about 80 to 100 babies.'

Paediatric surgeon, Dr Joao da Fonseca is checking up on one of his infant patients.

Dr Da Fonseca: 'This baby has got this enormous hernia. It was supposed to be done today. And we arranged for everything - we arranged for ICU beds. Unfortunately, at the last minute, someone on the staff fed the baby, so we had to cancel, because he can't be [operated].'

Devi: 'So, another day?'

Dr Da Fonseca: 'In another day or two, or three - when we have another ICU bed, because one of the big constraints that we have is the availability of ICU beds.'

That means this baby suffering from a lung disease and a massive hernia will wait indefinitely for surgery.

[08h00] Thirteen kilometres across town is Johannesburg Hospital.

Derek Watts (Carte Blanche presenter): 'The day is just starting at the paediatric surgery ward here at Johannesburg Hospital, and the registrars are just about to start making their rounds.'

Dr Baneigh Bal (Paediatric surgeon): 'This four-year-old girl came last night from Edenvale Hospital [because] they didn't have the equipment to deal with the problem. The child has a coin in her oesophagus. [Holding X-ray to the light] You can see it's very obvious - a massive coin. It's probably a 50 cent piece.'

Paediatric surgeon, Dr Baneigh Bal has been in public service for 14 years. 

Dr Bal: 'And this [50 cent coin] must be removed.'

In the paediatric ICU ward conditions are far from ideal.

Derek: 'Doctor, just walking in here it's a different feeling. It's an ICU, but looking around, just abut every little bed is full.'

Dr Bal: 'It's a constant source of discontent among the paediatric surgeons. But we all know there is a shortage, so we have to accept it. I've been doing this now for 14 years, and every week there is something.'

Derek: 'So, in truth, we are saying that young lives are being lost that could have been saved?'

Dr Bal: 'The short answer is yes. By definition, if there are not enough ICU beds for the babies, there would be an increase in mortalities. This is a logical assumption, yes.'

There wasn't an ICU bed for this baby. She was born with her bowels outside her body - it's a condition called Gastroschisis. And, unless treated immediately, it's fatal.

Dr Daniel Surridge (Registrar): 'You just have to be resourceful and use what you've got.'

Registrar, Dr Daniel Surridge, took her into his care.

Dr Surridge: 'We treat these babies by putting a bag over their bowels. I put the bag on in casualty, and she was doing okay. And we watched her for a little while, and she actually crashed - in casualty. We had to resuscitate her back, and we then called ICU again and said, 'Now we have a problem'.'

So ICU had to move out one of their less critical patients to save this life. Critical to the treatment of these babies is a specialised bag. 

Dr Bal: 'We use them - although they're supposed to be disposable, because they're so expensive - we clean them, sterilise them and use them again.'

These lifesaving bags are simply not in the hospital's budget.

Dr Bal: 'So, for a number of years I had to buy these bags out of my own pocket. They are about R 2 500 each.'

Derek: 'So she will have an operation in the next day or two?'

Dr Bal: 'I think, in fact, she's booked for today ... to close the defect today.'

The man who's going to perform the procedure is Chief Paediatric Surgeon, Professor Peter Beale.

He's checking up on a critically ill little boy that he'd operated on two days before. 

He was admitted with massive bleeding from ulcers in his stomach.

Prof Beale: 'We operated on his abdomen to control the haemorrhage, and were fortunate to identify the site from which it was coming.' 

Without surgery he would have died. Still, this little boy was still refused a children's' ICU bed.

Prof Beale: 'He's actually lying out of the normal paediatric ICU, in one of the other ICUs in this hospital, because he didn't meet the criteria for access to a paediatric ICU bed.'

That's because he has HIV coupled with TB. Access to this adult ICU bed has kept him alive.

[09h00] Devi: In Soweto surgeons are busy with the first of a string of operations.

Professor Graeme Pitcher (Department Head - Paediatric Surgery): 'This is a little boy with a malignant tumour of the muscle. And now we're going to remove it - it's been half removed.'

Professor Graeme Pitcher heads up paediatric surgery here.

Prof Pitcher: 'Paediatric surgery has an enormous breadth of different pathologies. We operate in the abdomen, we operate in the chest, we do some neurosurgery - we are the last true general surgeons. For that we require a reasonable spread of really specialised equipment.'

Devi: 'Do you have what you need?'

Prof Pitcher: 'In some respects we do, but we need to keep on updating our equipment, and we need to keep on replacing the equipment that is damaged. And that is a problem - we've not been able to get equipment here for the last two-and-a-half years.'

Surgeons here are severely compromised. But, they're beating the odds to save these young lives.

Prof Pitcher: 'We are putting in use 'Brak' therapy, which means we can give the radio therapy to a very localised area of tissue.'

There are only about thirty paediatric surgeons in the country.

One of them is Dr Da Fonseca. He's about to perform an operation that could have been completely avoided had the hospital owned a piece of specialised equipment. Seven-day-old baby Musa was born with valves blocking his urethra. 

Dr Da Fonseca: 'So what we are going to do is by-pass the area where the blockage is, so that we can actually make a hole in the bladder so that the baby can actually start passing urine through this hole in the bladder. [To nurse] Another stitch please.'

This neo-natal theatre was built in the seventies. It's in serious need of an upgrade.

Dr Da Fonseca: 'All this is very old equipment. It is not really ideal. Some of this may just slide right off, because they are so old and worn off.'

Dr Ellen Mapunda (Paediatric surgeon): 'This baby could have been spared this particular operation if we had the cystoscope ... the right cystoscope.'

Dr Da Fonseca: 'Well, yes - that is really very important.'

Dr Mapunda: 'So this is an added operation for the baby.'

Dr Da Fonseca: 'So this baby, instead of one operation, is going to have three.'

It's a frustration for Dr Ellen Mapunda.

Dr Mapunda [sketching on paper to demonstrate]: 'So what we needed was to have a scope that went through here. So it would just cut those, and open it now, so that the urine can just flow.'

Devi: 'That's it?'

Dr Mapunda: 'That's all. So because we don't have that instrument for this size of baby, we ended up making that big cut on the stomach.'

Devi: 'So the baby has to grow to fit the scope that you have?' 

Dr Mapunda: 'Yes, we don't have the small scope.'

Dr Da Fonseca: 'We ordered it long ago, but...'

Devi: 'But is it an expensive piece of equipment?'

Dr Mapunda: 'It is expensive, yes.'

Devi: 'What - millions?'

Dr Da Fonseca: 'No, no, no, no...'

It costs about R60 000 - money that could have saved this little baby and others like him the trauma and risk of three operations.

Dr Da Fonseca: 'We are the kings of improvisation. We improvise at every moment.'

Prof Pitcher: 'And there are other things we do that have special needs that you can't duplicate other pieces of equipment to use for. The requests go into this Behemoth of an enormous system that we as paediatricians don't understand. And the bottom line is that the equipment does not come out the other side. So I'm not sure what the reasons for that are. We've had great difficulty getting our surgical equipment to do these procedures.'

[11h30] Derek: Back at Johannesburg Hospital, Professor Peter Beale is well into his day.

Derek: 'This theatre operated just for the day and, as an outsider, it just looks heck-of-a busy.'

Next on the list is Shadila. She's the little girl who'd swallowed a coin. Hers is a simple procedure. But that doesn't take away the worry for her mother, Ina.

Derek: 'She'll be fine, Ina... it's not a big procedure.'

Prof Beale: 'We don't know exactly how long this coin has been in this child's oesophagus. It has been said to have been there for about two weeks, but I think that's an estimate. If it has been there for a period of time it could have eroded into the wall of the oesophagus, or it could erode right through the wall of the oesophagus.'

Derek: 'It just looks painful.'

Prof: 'Right, so now you take the whole lot out together - the coin mixed up with a trachea or two... But there it is.'

Nurse: 'It doesn't look like that but when I checked at the number it's a five cent.'

Derek: 'Five cents....'

[11h45] Devi: At Chris Hani Bara, doctors are about to work through lunch.

Devi: 'I am at the neo-natal ICU. It's impossible in one shot to show you how busy it is. For example, there are 11 babies there [points back], 12 babies there [points right], 13 babies there [points forward] on the other side and another 12 right on the other side of the wing [points left].'

Most of these babies are in what's called 'transitional high care'. But for the seriously ill, there are only 12 ventilated ICU beds. It's just not enough for a hospital that delivers 24 000 babies a year.

Dr Sithembiso Velaphi (Department Head - Neo-natal ICU): 'So we will need about 22 ICU beds. I'm not counting delivery that comes from the Soweto clinics.'

Neo-natal ICU is under the charge of Dr Sithembiso Velaphi. 

Dr Velaphi: 'When people phone me asking for an ICU bed and I say, 'I don't have an ICU bed,' it hurts me because I know to the daughter, to the colleague who is asking for the bed, that means that's the end. Or, it means the patient must wait - but that waiting can make the health deteriorate.'

Devi: 'The baby we saw upstairs who needed the hernia operation could very well get that operation because a bed in the ICU neo-natal ward has just become available.'

But minutes later, there's a dramatic turn of events.

Prof Pitcher: 'What has happened in this very busy ward is that one of the babies has deteriorated and it has deteriorated to a point where he actually needs to be resuscitated. And a doctor you can see in the background is resuscitating that baby. If he's successful that baby will require an ICU bed. We thought 10 minutes ago that we would be having a bed available for our case and in the interim - the time that we've been speaking - this baby has got ill.'

Devi: 'It's a tough call every day... I can see it every minute.'

Prof Pitcher: 'It's a minute-by-minute call.'

Sadly, this baby later died.

[12h15] Derek: In Johannesburg, Ina anxiously waits for her little girl to come out of theatre.

Derek: 'I think that here [hands over coin in jar] is something you'll want to keep.' 

Nurse: 'She's a little bit sleepy....'

Derek: 'She's fine now.'

Next up is the little girl who was born with her bowels outside her body. This is the only country on the continent where these babies have a fighting chance. Professor Beale is about to remove the gastroschisis bag. 

Prof Beale: 'These are custom-made by a company in the United States. But they are meant for single-use purposes. But we in fact sterilise them and use them again - it's a necessity in our environment.' 

Derek: 'What causes this condition?'

Prof Beale: 'It's unknown. There have been theories about gastroschisis, but it's a condition that's not genetically associated or related at all.' 

This is a relatively simple procedure. It's one of 14 that this team hope to get through today.

Prof Beale: 'So we really work under pressure to be able to get through our workload.'

Derek: 'But that's not through a lack of surgeons?'

Prof Beale: 'No, not through a lack of surgeons. It's because of budget constraints and because they, I think, misguidedly decreased the number of available anaesthetics staff in this hospital.'

A year ago, the hospital retrenched 20 anaesthetists. So now doctors have to cram their surgeries into two theatre days.

Prof Beale: 'So we are taking a bit of trouble to achieve the best prosthetic results possible for this baby. Because we are mindful of ways that babies wear the scars we make on them - and we leave them with - for the rest of their days.'

Derek: 'So this little girl will spend about two weeks in hospital and go home. There are very few scars in today's operation. I'm always very humbled by the dedication and expertise of these surgeons - the whole team here. And it's a tragedy that they don't get the right support and equipment.'

[16h30] Devi: At Chris Hani Baragwanath an ICU bed has opened up. That's great news for Dr Da Fonseca. His tiny hernia patient can now have his long-awaited surgery. 

But before surgeons can scrub up, there's another drama.

Dr Da Fonseca: 'Now, we have reached the end of the list - the time to operate the baby - and somehow someone misplaced the consent form and so on. There is no consent, there is no file and we cannot do the case.'

We're on our way to the neo-natal ward when nurses bring the baby down. They'd found the file. 

Nurse: 'Consent is not signed....'

Man: 'I'll sign consent.'

It seems this baby is determined to have his day in theatre. 

Dr Ellen Mapunda is performing the operation.

Dr Mapunda: 'Even though this baby is quite a sick baby - it is still on oxygen - we need to do this procedure because the hernia could complicate.'

Today, there are no complications for this baby or any of the other paediatric surgery patients.

Dr Joao Da Fonseca ends the day with a final check-up on his babies.

Devi: 'Baby is doing well?'

Dr Da Fonseca: 'Very well, actually extremely well.'

Devi: 'What does it feel like knowing that this doctor has saved your baby's life?'

Mom [Hugs Dr Da Fonseca]: 'Incredible.'

Dr Da Fonseca: 'You're welcome.'

For doctors like Joao to continue their miracle work they need huge support. 

Derek: At both hospitals, old equipment desperately needs to be maintained or replaced. There's also a massive demand for ICU beds, training equipment and a whole list of specialised surgical gear.

Derek: 'Is the hospital quite receptive to corporate wealth with certain aspects?'

Prof Beale: 'Yes, I think they're only too pleased that we embark on public-private corporate partnerships to supplement the healthcare system. In my mind that's the way of improving the standard of healthcare in the public hospital system.'

Producer : Odette Schwegler 
Presenter : Derek Watts